Brancel Bicycle Charter Application Form

Brancel Bicycle Charter Application Form
P.O. Box 107
Sun Prairie, WI 53590
[email protected] (email)
608-215-5939 (M)
Please fill out one form per person, mail or email form, then mail check made out to
Brancel Charters. You must be a RAGBRAI registered rider to use our services.
Name ______________________________________________________
Address ____________________________________________________
City, State & Zip Code ________________________________________
Phone Number ______________________________________________
Email Address ______________________________________________
Wristband number (email it when you receive it in May)______________
Names of others in your group or group name ______________________
Birthdate
Option 1) Transportation from ending town to beginning town on July 18 and daily
baggage transportation for the week as part of our group: $345 ____________
a) Daily Towel Service : $20 ______________
b) Extra charge for Recumbants: $20 __________
Enter dollar
amounts, not an x
Option 2) Transportation only from ending town to beginning town on July 18: $150 ________
a) Extra charge for Recumbants: $20 ___________
Option 3) Daily camping / baggage service for the week (no bus trip): $210 ____________
a) Daily Towel Service: $20 ____________
Option 4) Daily camping / baggage service for less than a week: $35 per night ______
Prior Passenger Discount: Subtract $5 for each prior year you have been a customer with us (up to
a maximum of $50 for option 1, $25 maximum for option 2 & 3) : _______
(Enter as negative number)
$0
Total: __________________
We will provide a full refund to those who are not selected in the RAGBRAI wristband lottery if we are notified by May 31. We will
provide a refund, less a 15% cancellation fee, through June 17. From June 18 to July 8 we will provide a refund, less a 25% cancellation
fee, only if we are able to the fill the spot. July 9 and after we have a no refund policy.
In consideration of Brancel Charters’ acceptance of my registration to participate in RAGBRAI XLIII, I hereby for myself, my heirs and
assigns: release, indemnify, and agree to hold harmless Brancel Charters’, its directors, officers, employees, agents, and participants who
may be performing functions for the ride, from any and all actions, claims, demands, administrative proceedings, judgments or decrees,
including attorney’s fees of any kind, including negligence on behalf of Brancel Charters', its directors agents, employees, officers,
assigns or participants that may arise out of my participation RAGBRAI XLIII.
______________________________________________________________________
Signature
Date
Signature of parent (if under 18)
`